The Pharmaceutical Journal
Vol 277 No 7414 p234
19 August 2006

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Academic medicine crisis? more
Protecting the gentle and intelligent vulture more
Attach greater value to centuries-known benefits of exercise more
Actions and attitudes: the sense of responsibility is paramount more

Academic medicine crisis?

In the 22 July edition of The Lancet, a primary care physician from Belgium and a cardiologist from Texas raise the intriguing question of whether academic medicine is neglecting the value of clinicians for training purposes in favour of medical researchers. Academic medicine, it is argued, requires not only good scientists and researchers but also good clinicians who will close the gap between the laboratory and everyday general practice.

We live in a medical culture that calls for publication of results of trials at any cost. The result is that many doctors find it difficult to balance the demands on their time and resources. In the US individuals who work in academic institutions have to compete with doctors in the private sector to make a living and academic medicine is drifting ever further from the bedside to concentrating its resources into the conference room. However, those who excel as clinicians should be recognised and given their proper role in academia. A large part of this involves teaching and training medical students at the bedside of patients. Thus, academic medicine should provide dual systems, one for researchers and one for pure clinicians, each supporting the other.

Recent changes in medical school curricula emphasise early exposure to patients and co-operation with community based clinicians, with expert clinical experiences seen as a stimulus to practice. Yet the absence of research in primary care could lead to overinvestigation of the patient, inappropriate treatment, and delay in diagnosis. Despite changes in the health care system and in medical education, students encounter a chilling aspect of primary care, with further growth in specialisation.

There is a bias towards basic research and against clinical research. Many medical journals seem reluctant to publish results of general practice research. The extent to which research can affect clinical practice and its possible effect on patient wellbeing tend not to be taken fully into account.

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Protecting the gentle and intelligent vulture

Byron commented in ‘The bride of Abydos’ that: “The rage of the vulture, the love of the turtle, / Now melt into sorrow, now madden to crime”. People have for centuries taken a poor view of vultures, but their reputation may not be deserved.

According to a comment in the 16 June issue of Science “They may look mean, but they are gentle and intelligent birds”. This verdict is attributed to the director of the vulture unit in a wildlife centre in South Africa, who nevertheless agrees that it is hard to warm to these creatures. Their evil reputation stems from the fact that they are essentially scavengers, which gorge themselves on carrion.

Conservationists who have undertaken studies of the birds have commented that for millennia humans and vultures had enjoyed a love-hate relationship. The ancient Egyptians worshipped vultures, pastoralists valued their ability to spot dead cattle from a great distance, shamans thought they were clairvoyant and Parsees encouraged them to consume human corpses.

Now several of the 15 species of Old World vulture are officially regarded as threatened or endangered. Two years ago it was reported that the anti-inflammatory drug diclofenac, used to treat cattle, was responsible for a 97 per cent decline in the number of vultures of three species found in the Indian subcontinent. They are now classed as critically endangered, but they became protected species only after some delay. And although India has now banned diclofenac in favour of meloxicam, Pakistan has so far failed to do likewise.

Vultures in Africa also have their problems. The African white-backed vulture, found across sub-Saharan Africa, often meets a sticky end by colliding with power lines. But the biggest problem has been in West Africa, where vultures have been slaughtered by deliberately poisoned carcasses intended to kill jackals and hyenas. Collectors seeking fetishes and traditional medicine have made the situation worse.

As scavengers, however, vultures are believed to halt the spread of anthrax in cattle by consuming infected carcasses, which apparently do them no harm. Vultures also rank as good parents, mating for life, laying one egg per year, and sharing nest duties.

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Attach greater value to centuries-known benefits of exercise

In our modern world we tend to discover ancient truths that have in fact been around for centuries, and then proclaim them as if they were new.

The philosopher Moses Maimonides (1135–1204), who studied Greek medicine and became physician to the sultan Saladin, commented: “As long as a person exercises and exerts himself a lot, takes care not to eat to the point of being completely full, and keeps his bowels soft, illness will not come upon him and his strength will increase. And whoever sits comfortable and takes no exercise, even if he eats the best foods and follows healthcare principles in other areas of his life, all his days will be full of pain and his strength will decline.”

A comment on this aspect of health in the 22 July issue of The Lancet reminds us that a great deal of effort, in the face of a rising prevalence of obesity in childhood, is being diverted to the problem of eating habits and food marketing, while the importance of physical activity is neglected. Nevertheless, physical activity is important not only to prevent obesity but also to guard against cardiovascular risks. Insulin resistance in childhood often relates to obesity, and physical exercise improves insulin sensitivity, as well as having other beneficial influences in overall health. Research on children has suggested an association between exercise and cardiovascular improvement independent of degree of adiposity. Indeed, changes in physical activity and other lifestyle factors play independent roles in metabolism in young adults.

Modern habits have provoked debate about the nature and quantity of exercise required in childhood and adolescence. The common recommendation of moderate to vigorous exercise for 30 minutes daily is outdated and should be doubled at least. Schools should promote a greater effort in view of the growing awareness that exercise carries enormous future benefits for every growing child and young adult.

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And I quote…

Actions and attitudes: the sense of responsibility is paramount
“Our notion of responsibility centres on our understanding of people’s purposes. And responsibility is not just a legal matter. It covers a far wider area of life than mere blame and punishment. It covers the whole ownership of actions, the notions that we form of people’s characters, the grounds of our entire social attitude to them. In considering these things, we constantly concentrate on what we believe them to be thinking.”
— Mary Midgley: ‘The myths we live by’ (2003).

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